Understanding Alcohol Abuse and Addiction

Steve HansonAssociate Commissioner

New York StateOffice of Alcoholism & Substance

Abuse Services

Steve.hanson@oasas.state.ny.us

REWARD CIRCUIT

Homer Says…

If it felt good, do it again…

and again

If it felt good, do it again…

and again

CravingAmygdalaAmygdala

Generalizes to other Substances

GOSTOP

Powerful Urge

Binge Behavior

Loss of Control

Decreased Inhibitions

Impaired Motor Control

Family Problems

Poor Performance at Work

Criminal Behavior

Emotional Problems

Ambivalence

Feelings of Guilt

Neglecting Hygiene

Major Loss of Focus

Regrets

Why Do People Drink?

• Curiosity• Enjoy the Beverage• Cultural Practices – Peers• Makes us feel better/different• Dependency

Addiction is a Brain Disease

Prolonged Use Changes the brain in Fundamental and Long Lasting Ways

SPECT IMAGES

NORMAL 3-4 DRINKS/DAY

Alcoholic v. Normal Brain

Non-Alcoholic Drinker• .05 Diminished alertness, impaired judgment• .10 Increased reaction time, impaired motor

skills• .15 Increasingly impaired motor responses• .20 Obvious intoxication• .25 Staggering; grossly impaired motors skills• .30 Stupor; inability to communicate or

comprehend surroundings• .35 Surgical anesthesia; LD 1• .40 LD 50• .60 LD 100

Alcoholic Drinker• .00 Severe withdrawal—tremors, vomiting, delirium,

hallucinations, possible seizure• .05 Continued severe withdrawal• .10 Some relief of symptoms; discomfort• .15 Reductions in tremor and gastric

distress• .20 “Normal” range; appetite returns,

tremors not evident• .25 Comfortable• .30 Upper limits of tolerance• .35 Obvious signs of sedation, intoxication• .40 “Drunk” state• .50 Passes out from alcohol’s effect

Tolerance

Alcohol• Most popular drug of abuse• Probably the most physically toxic of

drugs • Damages almost every organ in the

body• Easy access, adults use, advertising,

relatively inexpensive.• THE DRUG for Youth

EndorphinsDrink

Endorphins

RewardStop Drinking

Endorphins

Craving

Block Endorphins with Naltrexone– Break Reward Cycle

Naltrexone

• For people who have stopped drinking, Naltrexone reduces the craving for alcohol

• Naltrexone does not help someone stop drinking or doing drugs, it is used to help people who have already stopped maintain abstinence

• Sold as ReVia (daily) Vivitrol (monthly)

Depressant Withdrawal and Overdose

Agitation

Coma

Death

SeizureDeath

OverdosePassing Out

ShakesDT’s

Physical Effects

• Vasodilator in skin - blood flow –warm flush – actually indicates loss of body heat.

• Reduction in REM (dream) sleep- important for feeling well rested – without feel irritable

• Sensory changes - Acuity of hearing and sight Pain – masked fatigue  

Physical effects• Burning sensation – warm going down –

esophagus and stomach irritated • Initial stimulation of respiration –

(disinhibited) – eventually depressed – overdose death due to respiratory arrest

Urine production – blocks anti-diuretic hormone – dehydrate – dry mouth

Physical Effects

• Hangover effect – nausea, headache, thirst, anxiety, the shakes – caused by rebound/build up of acetylaldehyde, and other substances.

Long Term Effects

• Gastrointestinal – esophageal varices – dilation of vessels – can bleed – possibly fatal

• Gastritis – Inflammation of stomach lining – nausea, vomiting, pain, bleeding

• Peptic ulcers – ETOH stomach acids

Long Term Effects (2)

• Duodenal ulcers – internal bleeding • Pancreatitis – pancreas makes

insulin – inflammation – fatal

Liver Problems

• Alcoholic hepatitis – onset of fever – death

•  Fatty liver – ETOH fat in blood stored in liver function -reversible

(6 drinks/day for 18 days – 8X fat in liver)• Cirrhosis –scar tissue in liver –

decreased liver fcn – reverse tolerance - can be fatal. Caused by acetylaldehyde.

Physical Effects (3)

P450 – creates toxins in blood – damage liver – also decreases testosterone and estrogen.

• Enlarged spleen • Fluid in abdomen• Cancer links to tongue, mouth, throat,

liver (especially linked with smoking)

Cardio/Circulatory effects

• – enlarged heart – heart attack • Arrhythmias Stroke risk• Hypertension in fat – coronary artery disease • loss of elasticity – hardening of arteries bleeding and bruising

Malnutrition

• Alcohol empty calories – decreased food intake

•  Poor diet – vitamin deficiencies – B vitamins•  Thiamine deficiency – Wernicke’s – rapid

onset – confusion, vision, ataxia, memory, stuporous,

•  16% die within 1 month of symptoms – brain lesions – reversible

Korsakoff’s

• Gradual - amnesia – short term• Confabulation – make up facts, etc.• Disoriented – brain lesions –

irreversible

Neurological Effects

• Brain Atrophy – Cerebellum• Larger Ventricles• Cognitive impairment

– Memory– Abstract thinking– Impulse Control– Etc.

Alcoholism

• Traditionally – Moral problem• Today – Disease model• Loss of control• Cannot safely predict how much will

drink• Prone to relapse

Disease Model

• Primary – not caused by something else• Progressive – It gets worse• Chronic – lasts a long time• Fatal – can kill you

• Other chronic diseases – Diabetes, Asthma, Heart Disease, Cancer, etc.

Alcoholism

• Prevalence – 10% of population are problem drinkers

• A portion of them are alcoholics• Genetic Factors

– Neurotransmitter models– Risk increased if parent is alcoholic

• Treatable not Curable

Neural Models

• Dopamine – excitement / reward• Endorphins – escape, pain relief,

craving• GABA – stress / anxiety• Serotonin – Never felt normal

Drinking patterns

• Constant intoxication• Daily use without gross intoxication• Binge users

Stages

• Prodromal –(before the disease)– Heavy drinking– Some problems

• Early– Onset of frequent problems– Hiding/lying about drinking– Tolerance /Blackouts– Loss of control

Stages

• Middle– Solitary drinking– Attempts to stop– Physical problems– Withdrawal / DT’s– Morning Drinking– Nutrition Problems

Stages

• Late– Serious Health problems– Reverse tolerance– Binges– Drinking to relieve shakes

CravingTrigger

Memory

Stimulation of NucleusAccumbens & Amygdala

Focus on Drug Anxiety Increases

ImpairedJudgement

Relapse

Are adolescents more susceptible to alcohol than

adults?• Adult studies suggest that the areas of

the adolescent brain that are remodeled are sensitive to the effects of alcohol

• Four pieces of evidence

Are adolescents more susceptible to alcohol than

adults?1. Adolescent rats are less

sensitive to the sedative and motor impairment effects of intoxication

Are adolescents more susceptible to alcohol than

adults?2. Adolescent rats are more

sensitive to the social disinhibition induced by alcohol use

Wanna lookfor some cheese

with me?

Sure!

Are adolescents more susceptible to alcohol than

adults?3. Adolescent drunk rats

perform worse on memory tasks than adult drunk rats

Ugh??

disrupts the hippocampus

brain damage in the PFC

converts information to

memory

plannedthinking

Are adolescents more susceptible to alcohol than adults?

4. Hyperexcitability issue

• Alcohol relieves hyperexcitability state

• Relief is temporary; continued seeking of alcohol is reinforced

• Hyperexcitability is a key characteristic of conduct disorder, ODD and ADHD, which are often co-morbid with alcohol use disorders

• Hyperexcitability….• may have its origins in neurological

deficits• found in non-alcoholic relatives -

suggests inheritance of this trait

• HAT• BOAT• CAR• BIKE• HORSE• STEAK• BUS

• HOUSE• LAKE• SHIRT• DOPAMINE• AMYGDALA• RIVER• LUNCH

• GREEN• BLUE• ORANGE• YELLOW• PURPLE• WHITE• RED

• ORANGE• PURPLE• GREEN • WHITE• BLUE• RED• YELLOW